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<html>
    <head>
        <title>actualizar historia clinica</title>
        <link href="estilo.css" type="text/css" rel="stylesheet">
        <meta charset="UTF-8">
        <meta name="viewport" content="width=device-width">
    </head>
    <body>
        <fieldset> 
            <form>
                <div>ACTUALIZAR HISTORIA CLINICA</div>
                <div class="left">
                    <label for="txtNombre"> Nombre completo: <span class="asterisco">*</span> </label> <input type="text" name="nombre" id="nombre" required>
                </div>
                <div class="right">
                    <label for="txtIdentificacion"> Identificacion: <span class="asterisco">*</span> </label> <input type="text" name="identificacion" id="identificacion" required>
                </div>
                <div class="left">
                    <label for="txtEdad"> Edad: <span class="asterisco">*</span> </label> <input type="number" name="edad" id="edad" required>
                </div>
                <div class="right">
                    <label for="txtGenero">Genero<span class="asterisco">*</span></label>
                    <label for="Maculino"><input type="radio" name="sexo" value="masculino"/>Masculino</label>
                    <br>
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="Femenino"><input type="radio" name="sexo" value="femenino"/>Femenino</label><br>
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="otro"><input type="radio" name="sexo" value="otro"/>Otro</label><br>
                </div>
                <div class="left">
                    <label for="txtDireccion"> Direccion: <span class="asterisco">*</span> </label> <input type="text" name="direccion" id="direccion" required>
                </div>
                <div class="left">
                    <label for="txtOcupacion"> Ocupacion: <span class="asterisco">*</span> </label> <input type="text" name="ocupacion" id="ocupacion" required>
                </div>
                <div class="right">
                    <label for="txtFecha"> Fecha de nacimiento: <span class="asterisco">*</span> </label> <input type="date" name="identificacion" id="identificacion" required>
                </div>
                <div class="left">
                    <label for="txtRaza"> Raza: <span class="asterisco">*</span> </label> <input type="text" name="raza" id="raza" required>
                </div>
                <div class="left">
                    <label for="txtEstado_civil">Estado civil:<span class="asterisco">*</span></label>
                    <label for="txtSoltero"><input type="radio" name="estado_civil" id="estado_civil" value="soltero(a)" />Soltero(a)</label>
                    <br>
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtCasado"> <input type="radio" name="estado_civil" id="estado_civil" value="casado(a)" />Casado(a)</label>
                    <br>
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtDivorsiado"> <input type="radio" name="estado_civil" id="estado_civil" value="divorciado(a)" />Divorciado(a)</label>
                    <br>
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtViudo"><input type="radio" name="estado_civil" id="estado_civil" value="viudo(a)" />Viudo(a)</label>
                    <br>
                    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtUnion_libre"><input type="radio" name="estado_civil" id="estado_civil" />Union libre</label>
                    <br>
                </div>
                <div class="left">
                    <label for="txtReligion"> Religion: <span class="asterisco">*</span> </label> <input type="text" name="religion" id="religion" required>
                </div>
                <div class="left">
                    <label for="txtLugar_nacimiento"> Lugar de nacimiento: <span class="asterisco">*</span> </label> <input type="text" name="lugar_nacimiento" id="lugar_nacimiento" required>
                </div>
                <div class="left">
                    <label for="txtT_movil"> Telefono movil: <span class="asterisco">*</span> </label> <input type="text" name="telefono_movil" id="telefono_movil" required>
                </div>
                <div class="left">
                    <label for="txtT_fijo"> Telefono fijo: <span class="asterisco">*</span> </label> <input type="text" name="telefono_fijo" id="telefono_fijo" required>
                </div>
                <div class="right">
                    <label for="txtVia_ingreso"> Via de ingreso: <span class="asterisco">*</span> </label> <input type="text" name="via_ingreso" id="via_ingreso" required>
                </div>
                <div class="right">
                    <label for="txtMotivo_consulta"> Motivo de consulta: <span class="asterisco">*</span> </label> <input type="text" name="motivo_consulta" id="motivo_consulta" required>
                </div>
                <div class="left">
                    <label for="txtEntidad"> Entidad: <span class="asterisco">*</span> </label> <input type="text" name="entidad" id="entidad" required>
                </div>
                <div class="right">
                    <label for="txtRegistrador"> Registrador: <span class="asterisco">*</span> </label> <input type="text" name="registrador" id="registrador" required>
                </div>
                <div class="left">
                    <label for="txtRemision"> Remision: <span class="asterisco">*</span> </label> <input type="text" name="remision" id="remision" required>
                </div>
                <div class="left">
                    <label for="txtFecha"> Fecha: <span class="asterisco">*</span> </label> <input type="date" name="fecha" id="fecha" required>
                </div>
            </form>
        </fieldset>

        <fieldset>
            <form>
                <title> Examen fisico </title>  
                
                <br><div class="left">
                    <label for="txtPeso"> Peso: <span class="asterisco">*</span> </label> <input type="number" name="peso" id="peso" required>
                </div>
                <br><div class="left">
                    <label for="txtTalla"> talla: <span class="asterisco">*</span> </label> <input type="number" name="talla" id="talla" required>
                </div>
                <div class="left">
                    <label for="txtAspectos_generales"> Aspectos generales: <span class="asterisco">*</span> </label> <input type="text" name="aspectos_generales" id="aspectos_generales" required>
                </div>
                <div class="left">
                    <label for="txtDiagnostico"> Diagnostico: <span class="asterisco">*</span> </label> <input type="text" name="diagnostico" id="diagnostico" required>
                </div>
            </form>
        </fieldset>
    </body>
</html>
